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STATE OF CALIFORNIA " 1 STATE WATER RESOURCES CONTROL BOARD""� +• UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B • YI . o' COMPLETE A SEPARATE FORM FORE TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a r(p 447u I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D. O B. MANUFACTURED 8Y: (Ar— C. DATE INSTALLED Y/YEAR) D. TANK CAPACIN IN GALLONS: �O OO H.TANK C ENTS IFA-11SMARKED,COMPLETEREMC. A. E�rl MOTOR VEHICLE FUEL ❑ { OIL 9, C. ❑ Ii RE R 8 3 DIESEL ❑ 6 AVIATIONGAS DE6 GASAHOLD ❑ 2 PETROLEUM ❑ SO EMPTY 1 PRODUCOPREM T IUM ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.is III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 5 -WALL ❑ s SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK CE-1,BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (P6mmyTMlk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ g9 OTHER ❑ 1 RUBBER LINED ❑ 2,pkKYD LWNG ❑ 3 EPDXY LINING ❑ s PHENOLIC LINING C.I TERIOR F-15 GLASS LINING 6 UNLINED ❑ 96 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 32,edfiTING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTK)N 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIF ABOVE GROUND ERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U RESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCT [ON A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LNED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U / RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELVUCOATING A U S 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNIWOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MON IHNG ❑O9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ ♦ AUTOAATICTANK GAUGING❑ 5 GROUND WATER MONITORING ❑ B TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILED WITH SUBSTANCE REMAINING Q GALLONS I INERTMATERIAL7 YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IPRINTEO A 6 AT REI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSEDOF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACIL"# TANK• G fI Fl�� STATE I.D.# =1ILll1 PERMIT NUMBER PERMIT APPROVED 8Y/DATEPERMR EXPIRATION OeTE > 7� FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED F'OIIOm16A6